Aetna Improperly Denies or Underpays Out-of-Network Claims

Aetna is now facing another set of claims calling into question its determination and payment methodology for out-of-network reimbursement. On September 4, 2015, six surgical centers in Texas (Allied Center for Special Surgery) filed suit in Harris County District Court against Aetna Health Inc. and Aetna Life Insurance Company (Aetna), claiming that Aetna underpaid or denied payment of more than 900 claims for treatment dating back to 2006. The lawsuit claims that Allied was underpaid nearly $34 million for the services provided. This case is one in a growing trend brought by providers seeking redress for how insurers are determining and paying out-of-network claims, including insurers’ alleged decisions to deliberately or creatively underpay or deny claims.

Allied contends it was providing “medically necessary care and treatment” to Aetna’s members on an out-of-network basis, according to the complaint. As a provider without a managed care agreement with Aetna, Allied’s reimbursement was determined solely by “Aetna’s own methodology.” Despite being an out-of-network provider, Allied contends that it contacted Aetna “on or before the date of services being rendered” and “obtained verification of insurance and received preauthorization for all treatment to be provided to the Aetna members at issue…” Allied went on to perform the services and later submitted claims to Aetna for payment based on Allied’s usual and customary charges.

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